UBC Objectives: Transition to Practice, UBC Objectives: Collaborator, UBC Objectives: Communicator, UBC Objectives: Health Advocate, & UBC Objectives: Manager
By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
After spending time with the Portland Hotel Society (PHS), I received feedback on competencies that are challenging for one to confidently know whether or not they're actually being met. One of the comments I received was, "Excellent charting and documentation." It's good to know that my preceptor thought my charting and documentation was "excellent," although by itself it doesn't really indicate what it was that made me competent with this skill. In any case, it is important to document clearly and concisely, making it easily understood by other clinicians, and making sure you have your charting done by the end of the day so that those same other clinicians who may need to obtain information about the visit you had can access any pertinent information readily. (Medico-legally, it is also important to document the advice you provided to patients regarding when are where to receive follow-up medical care and under what circumstances. Like any worthwhile medico-legal documentation, this is just good practice so that you ensure that you take the time to consider and counsel patients on this important piece of advice. It is also important to counsel appropriately about when patients need not re-present for a medical complaint, to spare patients and the health care system the burden of excess unnecessary repeat visits. That being said, it is also good practice to tell patients that if the situation changes - as may occur with a change in the quality or severity of their symptoms - or if they are ever concerned for whatever reason, to always just call or re-present for medical attention.)
Like a normal human vocabulary, as we grow and learn, we develop new words that can more succinctly describe what it is we want to communicate. It is much the same with medicine as well, and I expect with many other fields of work, where the learner gradually becomes less wordy communicating what is important to their colleagues. This comes along with experience and the development of greater awareness of what it is that your colleagues would appreciate knowing, and in medicine, develops alongside your understanding of what is medically pertinent and not. And this communication really is critical to providing good care when that care is a shared responsibility between many health care providers, much as it is with the Portland Hotel Society clinic and many other newer models of multi-provider care where more than one clinician provides care for a single patient. Even in clinics where each patient has one primary care physician, many of those clinics are making a shift toward a more interdisciplinary clinic model or "Patient's Medical Home" whereby various disciplines are providing a patient with medical care. Effective documentation in this context is requisite for providing effective patient care, and is only going to be more and more important in the interdisciplinary future of our health care system.
The above being said, shared patient care is not a new concept per se either, as family physicians have been referring patients for specialised medical care as long as the discipline of family medicine has itself existed. Even in modern interdisciplinary models such as at the Portland Hotel Society, there may still be the patient whose medical status warrants a more acute level of care than an outpatient clinic can support, and there are patients with such rare diseases that care by a specialist well versed in those disease processes is ideal. Accessibility to the latter may come with a lag at times, given the number of specialists practicing regionally in a given field of medicine. In any case, such action requires a referral, and the communication may not be in realtime. While I was at the Portland Hotel Society for 2 weeks, each week there was an outpatient I referred urgently to the Emergency Department (I provided a written letter of the circumstances for why I was referring care, as well as providing the important information from the patient's medical chart, expeditiously so thanks to a well-updated EMR system, and providing information so that I could be readily contacted). And each day there was at least one patient who presented after follow-up with a specialist for an uncommon disease process. On one occasion, clarification of the management plan was critical to ensure good patient care for a particularly challenging patient case: We called the Infectious Disease specialist who was managing one of our patients with a new diagnosis of HIV to clarify that our clinic actually had the ability to perform lab work and that the specialist could communicate what they wanted measured and how often so we could obtain this opportunistically when the patient presented (infrequently, to our chagrin) for outpatient medical care. This step meant having an appreciation for the barriers of this patient and the patient population in general to which they belong, and taking steps to mitigate these barriers in ways that are feasible. Spending time with PHS meant furthering my understanding of the extent and consequences of the barriers of patients who are street entrenched, along with seeing creative solutions to many of these barriers. Feedback I received from PHS included, "Thinks about the social determinants of health and the patient context when creating clinical plans," and I believe it was the examples laid out before me that primed my mind to be more sensitive to these barriers than I would have otherwise been. Patients were, for example, linked directly to various community health services beyond those delivered by physicians, with common examples being physiotherapy, mental health counselling, and detox treatment, and this was made possible through strong community connections. Being aware of the various services that different agencies offer and forging strong relationships with the providers of those services means being able to assist patients in accessing helpful services in a timely way. The above examples of inter-provider patient communication, and the ways in which I learned to integrate them into my care of patients on this elective, are what I believe led to the pieces of feedback I received on my evaluation form that state, "Appropriate referrals" and "Liaises with outside care providers to coordinate care." This is important feedback for me to reinforce these actions that are essential to provide good patient care.
Beyond making efforts to document information clearly etc, the medium is also part of what makes the message effective, and Electronic Medical Records (EMRs) are absolutely more effective as a communication and management tool compared to paper charting. (Albeit there is also a time and a place for verbal communication over the phone or in formal meetings, such as family meetings or ones where multiple disciplines and stakeholders are present.) At the Portland Hotel Society, they make effective use of their EMR by not only using it as a platform for effective charting and easy yet private sharing of patient information, but also as a tool to manage their practice, organizing tasks and creating reminders, communicating by tags and coloured alerts to indicate the status of the patient in the clinic (ex: that they are in with the physician, that they are seeing the nurse, that they have checked in and are still waiting to be seen, that their visit is complete but that the documentation from the visit is not finished yet, etc), and notifying various members of the team when there have been referral made to other health care providers, among other functions. I mean, I'll take the piece of feedback saying I was "Thoughtful about work flow and clinic pace," but in all honesty, the system would have made it a challenge not to be. I can't wait to have a future EMR in my practice to make the care I provide practical, efficient, and a heck of a lot more functional than sloppy handwriting on a vulnerable piece of paper.
That being said, by itself, an EMR doesn't by itself make a clinic functional and promote better care, but in a context where these are valued ways of operating and there are policies to benefit from the EMR, it can enhance a team's ability to do their job. The teamwork and collegiality at the Portland Hotel Society was truly exceptional, and even as a learner who was a temporary member of the team, I was welcomed and made to feel valued for the small part I had to play in patient care. An EMR system does not omit the need for the in-person sense of community at the clinic, but it does serve as a platform for continued communication and connection with the team once those relationships are created. I am fortunate to have been a part of the team at the Portland Hotel Society to appreciate how a truly functional health care team values patients and the other members of the interdisciplinary team, by what they communicated, how they communicated, and the little efforts to include each other in patient care when relevant. They also did little things that truly make a difference, like starting the day with a team check in, to ground each other and make space to value our humanity as people as well as employees. And having reasonable work hours, which keeps everyone sane. Alongside feedback regarding my clinical abilities, I received comments like, "A pleasure to work with and have on our interdisciplinary team" and "Respectful and collegial with the team," which is as much an indicator of my abilities to be a team player as it is to suggest how valuing teamwork can bring out those qualities in an organization.
A big part of residency is indeed learning to manage a very busy schedule and cope with all of life's other demands at the same time. Certainly I have developed my ability to more efficiently manage the multiple obligations of life beyond the demands of work that are often overwhelming. On the other hand, it has become apparent to me that the expectation of the work environment has a far greater effect on my ability to manage life than my skills to cope with less time. While at the PHS, I presented for work every day feeling recharged and ready to give it my all because I had enough time outside of clinic to read around cases and enhance my knowledge of how to treat the diseases more prevalent in the patient population (my evaluation from the PHS included, "Finished her opioid agonist therapy and injectable opioid agonist therapy courses and preceptorships during this rotation"), and I still had enough time to keep my fridge stocked with fresh food and go for dinner with friends in the evening. When I start working after graduation and join a community clinic, a priority for me will be to join an organization that not only values the Patient's Medical Home model, but one that also values the home lives of all of its team members, enhancing both my patients' and my own quality of life.